Provider Demographics
NPI:1134879919
Name:WEATHERLY, KYLIE GABRIELLA
Entity type:Individual
Prefix:
First Name:KYLIE
Middle Name:GABRIELLA
Last Name:WEATHERLY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11651 WINFIELD RD
Mailing Address - Street 2:
Mailing Address - City:WINFIELD
Mailing Address - State:WV
Mailing Address - Zip Code:25213-7975
Mailing Address - Country:US
Mailing Address - Phone:304-807-0086
Mailing Address - Fax:
Practice Address - Street 1:501 DANNER RD
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25303-2827
Practice Address - Country:US
Practice Address - Phone:304-807-0086
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-25
Last Update Date:2022-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant